Provider Demographics
NPI:1659715191
Name:TYSON, SIMMONE J (LPN)
Entity Type:Individual
Prefix:
First Name:SIMMONE
Middle Name:J
Last Name:TYSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 44TH ST
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-1009
Mailing Address - Country:US
Mailing Address - Phone:631-894-8203
Mailing Address - Fax:
Practice Address - Street 1:411 44TH ST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-1009
Practice Address - Country:US
Practice Address - Phone:631-894-8203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311969-1164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse